UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK CJA PANEL Application for Pro Hac Vice Admission to the CJA Panel PLEASE COMPLETE THE ATTACHED CRIMINAL JUSTICE ACT PANEL APPLICATION FORM. ~~~~~~ PLEASE RETURN THE COMPLETED FORM TO: LAWRENCE K. BAERMAN, CLERK UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK P.O. BOX 7367 100 SOUTH CLINTON STREET SYRACUSE NY 13261-7367 ATTN: Tracey Donovan American LegalNet, Inc. www.USCourtForms.com UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK CRIMINAL JUSTICE ACT ASSIGNED COUNSEL APPLICATION FORM - Pro Hac Vice Admission to the CJA Panel 1) Name: ______________________________________________________________________________________ (LAST) 2) Firm Name: (FIRST) (MIDDLE INITIAL) ____________________________________________________________________________ 3) Office Address:____________________________________________________________________________ _________________________________________________________________________________________ (CITY) (STATE) (ZIP CODE) 4) County:__________________________ NDNY Bar Roll No:_____________________________________ 5) Office Telephone No.: (_____)____________ Fax Number:(______)_______________________________ 6) Home Telephone No: (_____)____________ E-Mail Address:____________________________________ 7)* Federal Tax Identification No.: __________________ 7A)* Social Security No.: ___________________ 8) Education: Law School:_____________________________________________________________ Date:__________ 9) The highest court to which you are admitted: ______________________________ Date: _______________________ 10) _____ This will be my first CJA Panel assignment in the NDNY. 11) _____ I am familiar with the current NDNY Local Rules & the Fed.R.Crim.P. 12) _____ I have never been censured or suspended from practice. Dated: ____________________ ____________________________________ Signature * IF USING A LAW FIRM EMPLOYER IDENTIFICATION NUMBER, YOU MUST ALSO PROVIDE YOUR SOCIAL SECURITY NUMBER ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------FOR COURT USE ONLY: Attorney is GRANTED Pro Hac Vice Admission to the CJA Panel Case Number: ______:_______ CR __________________ Judge: ____________________________________ Date: ________________ ____________________________________________ Hon. Frederick J. Scullin, Jr., Chief Judge ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- w:\cja\CJA Panel PHV Application 01/03/2002 American LegalNet, Inc. www.USCourtForms.com